Name *

First Name

Last Name

Emergency Contact Name *

First Name

Last Name

Emergency Contact Phone *

Country

(###)

###

####

Have you ever had a heart condition, stroke, palpitations, murmurs or pains in the chest? *

Yes

No

Have you ever had chest pain brought on by physical activity? *

Yes

No

Have you experienced chest pain in the last month? *

Yes

No

Has a doctor ever recommended that you only take part in medically supervised activity? *

Yes

No

Do you have an injury, illness, back, bone or joint condition that may be aggravated by physical activity? *

Yes

No

Do you have asthma, diabetes, epilepsy, hernia, dizziness, gout, circulation problems, arthritis or an ulcer? *

Yes

No

Do you tend to faint, lose consciousness, loose your balance or fall over easily? *

Yes

No

Are you on any medication which may affect you during your class? *

Yes

No

Have you had an operation in the last 6 weeks? *

Yes

No

Are you aware of any other reason why you should not exercise or should not exercise without medical supervision? *

Yes

No

Are you currently, or have you been pregnant in the last 6 months? If yes, do you have any symptoms that your instructor should be aware of? *

Yes

No

I declare that to the best of my knowledge, the information given is correct and I know of no reason why I should not participate in classes. I understand that I attend classes entirely at my own risk. *

I AGREE

I DISAGREE